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Challenges in Liver Transplant: Dealing with Portal Vein Thrombosis

Portal Vein Thrombosis is frequently encountered during liver transplantation. The extent of thrombus decides surgical options for portal reperfusion. Pre-operative CT scan is accurate for diagnosis of presence and extent of PVT. However, in a few patients (especially those on deceased donor waitlist) the thrombus can progress in extent from time of CT scan to time of transplant and can pose difficult challenges to surgeons. The surgical options which have been commonly described are thrombectomy, interposition grafts, systemic-portal (cavo-portal, renoportal) transposition, and multi-visceral transplantation. Use of collaterals for portal reperfusion has been rarely considered as an option because of concerns about long term anastomotic patency after the resolution of portal hypertension.

Intra-operatively, Grade IV portal vein thrombus was seen and hence interposition graft was not considered. Cavo-portal Hemi transposition was not done as that would not have addressed the left-sided portal hypertension.

End to side anastomosis between donor portal vein and spleno-portal collateral was done for reperfusion which was uneventful.

At one year follow up, the anastomosis was patent on Doppler ultrasound with the normal waveform in the portal vein. Upper GI endoscopy demonstrated complete resolution of esophago-gastric varices.

Thrombectomy and interposition grafts are preferred techniques for management of PVT. Portal reperfusion through collaterals is simple, effective for resolution of portal hypertension, and has long term patency. Hence, it may be preferred over Cavo-portal transposition and multi-visceral transplantation for extensive (Grade IV) Porto-mesenteric thrombosis.

Dr. Manish C Varma, MS (AIIMS), DNB, Fellow- American Society to Transplant Surgeons (MGH, USA), (Professor & Head, Liver transplant & HPB Surgery (Consultant Cardiologist)

Dr. L. Sasidhar Reddy, MS, FMAS, DMAS, Fellowship in Liver transplantation(GRIPMER, Delhi) (Consultant, Liver Transplant & HPB Surgery)